Nursing Practice I INSTRUCTIONS:

NURSE LICENSURE JULY 2011

1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 2. Write the subject title NURSING PRACTICE I on the box provided. 3. Shade Set Box A on your answer sheet if your test booklet is Set A; shade Set Box B if your test booklet is Set B.
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Situation: The body fluids move using the principle of Osmosis and Diffusion. Osmosis is the movement of fluid from an area of lower concentration going to an area of higher concentration while Diffusion is the movement of Gas or fluids from an area of higher concentration going to an Area of lower concentration. This affects the isotonicity or concentration of the body in relation to its solutes and solvents. 1. D5NSS is an example of: A. Isotonic B. Hypotonic D. Blood product C. Hypertonic

1. The most abundant cation in the intracellular fluid is: A. NaB. Na+ C. K1. Why is insulin given in client's with Burns?

D. K+

A. Insulin lowers the potassium level in the blood thus decreasing Hyperkalemia B. Insulin lowers the blood glucose level thus decreasing Sugar C. Insulin improves energy, stamina and prevents infection in burn clients D. Insulin improves the metabolism of clients with Burn injury to enhance tissue repair and cellular regeneration D. D5W

1. Which of the following is NOT an isotonic solution? A. D5 1/2NSS B. 0.9% NaCl C. LR

1. In Clients with Diabetes Mellitus, The greatest complication that could occur is related to: A. Infection B. Hypovolemic Shock C. Stroke D. Acidosis Situation: Cases are classified as either CIVIL, ADMINISTRATIVE and CRIMINAL. 1. If a crime is punishable by imprisonment with fines, this is an example of: A. Criminal case C. Civil case B. Administrative case D. Special case 1. A nurse intentionally administered a high dose of medication to the client. The case that will be filed against that nurse is: A. Criminal case C. Civil case B. Administrative case D. Criminal and Civil 1. Karla is working on a government hospital and he has been caught stealing from a client. He took the client's phone and cash and she admitted that she did so. The case that will be filed will probably be: A. Criminal case C. Civil case B. Administrative case D. Criminal and Administrative 1. Jake AWOL after 6 months and failed to complete the 1 year contract set by the hospital. If the hospital will take action, Jake will face which case? A. Criminal case C. Civil case

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B. Administrative case

D. Criminal and Administrative

1. Margarita, A nurse working in PGH, divulged to a patient that Chris, another

patient in the same hospital, has a UTI and working as a male escort. You heard the conversation and apprehended margarita. You would expect that the type of case that will be filed against her is: A. Civil and Criminal C. Civil and Administrative B. Administrative case D. Criminal and Administrative SITUATION: Teaching and learning is a nursing responsibility. The ability of a nurse to educate and change the clients behavior through health teaching is one important goal of nursing. 1. A clients hypertension has been recently diagnosed. The nurse would plan to do which of the following as the first step in teaching the client about the disorder? A. Gather all available resource material B. Plan for the evaluation of the session C. Assess the clients knowledge and needs D. Decide on the teaching approach 1. A diabetic client who is performing self-monitoring of blood glucose at home asks a clinic nurse why a glycosylated hemoglobin level needs to be measured. The nurse should plan to incorporate which of the following into a response? A. This laboratory test is done yearly to predict likelihood of long term complication B. This laboratory test gives an indication of glycemic control over the last 3 months C. It is done as a method of verifying the accuracy of the meter used at Home D. It is done to predict risk of hypoglycemia with the current diet and medication regimen 1. In teaching the sister of a diabetic client about the proper use of a glucometer in determining the blood sugar level of the client, The nurse is focusing in which domain of learning according to bloom? A. Cognitive B. Affective C. Psychomotor D. Affiliative 1. Which of the following is the most important condition for diabetic client to learn how to control their diet? A. Use of pamphlets and effective teaching devices during health instruction B. Motivation to be symptom free C. Ability of the client to understand teaching instruction D. Language and appropriateness of the instruction 1. When you prepare your teaching plan for a group of hypertensive clients, you first formulate your learning objectives. Which of the following steps in the nursing process corresponds to the writing of learning objectives? A. Planning B. Implementing C. Evaluating D. Assessing SITUATION: Nursing is a profession. Miss Linda is a newly appointed nurse in a hospital in Manila. Born May 1985, Her knowledge of nursings professional

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development is required in order to project the profession in a way that it lifts the standards of nursing.

1. Mrs. Linda defined nursing as one of the following except: A. Assisting individual, family and community in attaining health B. Assisting basic health needs C. Establishing nursing diagnosis and implementing nursing care D. Diagnosing, treating, prescribing medication and doing minor surgery 1. PNA was established in: 1. 2. 3. 4. 1922 1926 With Mrs. Rosario Delgado as first president With Mrs. Anastacia Tupas as first president A. 1, 3 B. 1, 4 C. 2, 3 D. 2, 4

1. As a national nurses association, it is characterized as follows except: A. Both a professional body and a labor union B. Affiliated with the International Council Of Nurses C. Advocating for improved work and life condition of Nurses D. Accrediting body for continuing education program 1. CPE Units per year is needed for license renewal. The number of CPE units in 3 years should be: A. 20 units B. 30 units C. 60 units D. 100 units 1. To manifest that you want to quit from your job and discontinue the services you render after the completion of a contract, you will file a: A. Certificate of resignation B. Honorable dismissal C. Certificate of termination D. Resignation letter 1. In resigning for her job as a staff nurse, she must give advance notice of: A. 15 days B. 30 days C. 45 days D. 60 days 1. In case a nurse filed a sick leave and plans to return to work after, She must show her: A. Back to work certificate C. Death certificate B. Fit to work certificate D. Medical certificate 1. A certificate that will show that a nurse met the requirement set by the Philippine Government to practice the profession is: A. Diploma C. Nursing License B. Certificate of passing D. Board Certificate/CoR 1. Nurses in the Philippine government also felt the need to organize themselves, this leads to the creation of: A. National League of Government Nurses

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B. National League of Filipino Government Nurses C. National League of Philippine Government Nurses D. Philippine Government Nurses Association

1. The founder of NLPGN, during her lifetime, exemplified professional dignity,

high level of intelligence and leadership ability, as well as moral integrity. She was a good model, who, like Florence Nightingale, initiated reforms and worked for the improvement of the nursing profession and health care in the Philippines. The name of the NLPGN Recognition award was also named after her: A. Anastacia Giron Tupas C. Annie B. Francisca Delgado D. Annie Sande

Situation: Measurement of Vital signs is necessary skill a nurse should possess. Remember that taking Vital signs is one of the most common routine activities that an entry level nurse will do in practice. 1. When taking the oral temperature of a client who smoke or drink hot or cold fluids, it is necessary that the nurse should wait for how many minutes? A. 15 minutes B. 30 minutes C. 5 minutes D. 1 hour 1. When taking the blood pressure, the nurse should properly wait for a period of time when the client has just arrived to the health center. How many minutes should a nurse wait before taking the blood pressure of this client? A. 15 minutes B. 30 minutes C. 5 minutes D. 1 hour 1. The nurse knows that he above: A. 15 mmHg based on B. 15 mmHg based on C. 30 mmHg based on D. 30 mmHg based on should pump the cuff of the sphygmomanometer the the the the Palpatory systolic BP Auscultatory systolic BP Palpatory systolic BP Auscultatory systolic BP

1. The nurse should warp the BP Cuff evenly around the clients arm ensuring that it is well place approximately: A. 1 cm above the antecubital space C. 4 cm above the antecubital space B. 1 inch above the antecubital space D. 2 inches above the antecubital space 1. In taking the blood pressure of an obese client, the nurse used an ordinary size cuff and therefore an error will most likely occur. The nurse knows that if this is the case, The Blood Pressure will be: A. False high B. False low C. Undetermined D. Normal Situation: Safe nursing practice involves an understanding of the law. 1. In the A. B. C. D. Philippines, this law is : The Philippine Nursing Act of 2002 or R.A. 9173 the Philippine Nursing Act of 1991 or R.A. 7164 IRR or Resolution 425 of 2003 Republic Act No. 8981

1. The Philippine Nursing Act delineates the scope of nursing. It specifies that independent practicing nurse is responsible for: A. health promotion and prevention of illness B. administration of written prescription for treatment and therapies

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C. rehabilitative aspect of care D. Collaborating with other healthcare providers for health restoration and alleviation of suffering

1. Standards of care provide the legal basis for evaluation of nursing practice or malpractice. Its functions include all EXCEPT: A. used by nurse experts to define what appropriate nursing practice is in a given situation B. used to measure or evaluate nursing conduct to determine if the nurse acted reasonably as any prudent nurse would under similar circumstances C. used to delineate the scope, function and role of the nurse D. use to measure or evaluate the conduct of nurse specialists who are certified in their own specialty fields 1. As a standard in ethics, this represents an understanding and agreement to respect another persons right to decide a course his or her own destiny: A. Autonomy C. Beneficence B. justice D. nonmalifecence 1. The Code of Ethics refers to standards of behavior or ideals of conduct. The ability to answer for and stand by ones action refers to: A. accountability C. advocacy B. veracity D. responsibility Situation 18: An understanding of the factors influencing the health care delivery system will enable nurses to adjust to change, create better ways of providing nursing care and develop new nursing roles. 1. Wellness clinics and health education activities have been integrated in government hospitals to render appropriate services. Which of the following purposes LEAST helps clients in cases of these health promotion activities? A. maintain maximum functions C. promote health habits B. reduce the costs of health care D. identify disease symptoms 1. With regards to illness prevention activities as part of nursing care, which of the following will help clients MOST? A. maintain maximum function C. promote habits related to health care B. reduce risk factor D. manage stress 1. By experience, which of the following nursing goals are MOST often overlooked by nurses and other members of the hospital team in the care of their clients in the hospital? A. illness prevention C. diagnosis and treatment B. health promotion D. rehabilitation of patients 1. Which of the following health care agencies is usually family-centered, relatively recent in popularity and oftentimes focuses on maintenance of comfort and satisfactory lifestyle of clients in the terminal phase of illness? A. non-government organization C. community health center B. hospice D. support group 1. Which of the following is NOT a legally binding document but nonetheless very important in the care of all patients in any setting? A. Bill of rights as provided in the Philippine Constitution B. Scope of nursing practice as defined in R.A. 9173 C. Patients Bill of Rights (as adopted by American Nurses Association)

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D. Board of Nursing resolution adopting the Code of Ethics Situation: ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS.

1. During colostomy irrigation, the client complains of a cramping sensation with the fluid was introduced. Which of the following is a CORRECT nursing action? A. Temporarily stop the irrigation B. Clamp the irrigating tube C. Pinch or kink the irrigating tube temporarily D. Continue the irrigation 1. When A. B. C. D. are the colostomy appliance best emptied? When there is the sensation of pressure When there is the sensation of taste When there is the sensation of smell When it is full

1. The client asked the nurse, WHEN is the best time to perform irrigation? The nurse would answer: A. Early morning, before meals, upon arising B. Early morning, before meals C. Early morning D. Early morning, After meals 1. The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching? A. Hanging the irrigation bag 24" to 36" (60 to 90 cm) above the stoma B. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water C. Stopping irrigation for cramps and clamping the tubing until cramps pass D. Washing hands with soap and water when finished 1. The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen from the colostomy stoma should: A. take the specimen to the laboratory immediately. B. collect the specimen in a clean container. C. collect the specimen in a sterile container. D. perform a midstream clean catch collection.

1. You plan to teach Fermin how to irrigate the colostomy when: A. The perineal wound heals And Fermin can sit comfortably on the
commode B. Fermin can lie on the side comfortably, about the 3rd postoperative day C. The abdominal incision is closed and contamination is no longer a danger D. The stools starts to become formed, around the 7th postoperative day

1. When preparing to teach Fermin how to irrigate colostomy, you should plan to
do the procedure: A. When Fermin would have normal bowel movement B. At least 2 hours before visiting hours C. Prior to breakfast and morning care D. After Fermin accepts alteration in body image

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1. When observing a return demonstration of a colostomy irrigation, you know

that more teaching is required if Fermin: A. Lubricates the tip of the catheter prior to inserting into the stoma B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion C. Discontinues the insertion of fluid after 500 ml of fluid has been instilled D. Clamps of the flow of fluid when felling uncomfortable states, I will contact my physician and report: A. If I have any difficulty inserting the irrigating tub into the stoma. B. If I noticed a loss of sensation to touch in the stoma tissue. C. The expulsion of flatus while the irrigating fluid is running out. D. When mucus is passed from the stoma between the irrigations.

1. You are aware that teaching about colostomy care is understood when Fermin

1. You would know after teaching Fermin that dietary instruction for him is
effective when he states, It is important that I eat: A. Soft food that is easily digested and absorbed by my large intestines. B. Bland food so that my intestines do not become irritated. C. Food low in fiber so that there are fewer stools. D. Everything that I ate before the operation, while avoiding foods that cause gas.

SITUATION: Mastery of Intravenous therapy and all aspects that address the response of the client to complication related to it will help the new nurse in providing quality care.

1. One hour after the IV was inserted, Nurse Net found out that the 1 liter of

D5NSS was empty. Patient was in severe respiratory distress with pinkish frothy sputum. The most probable complication is: A. Speed shock B. Renal failure C. Congestive heart failure D. Pulmonary edema an IV of D5W is not infusing well on patient, it is best to first: Pinch the rubber part to flush out clogged blood Coil tube and squeeze hard Lower IV to check for return flow Restart the IV

1. When A. B. C. D.

1. The doctor ordered venoclysis of dextrose 5% in water one liter KVO for 24
hours as a vehicle for IV medications. How many drops per minute should the fluid be regulated? A. 20 drops per minute B. 5 drops per minute C. 10 drops per minute D. 15 drops per minute 1. The nurse is administering I.V fluids to an infant. Infants receiving I.V Therapy are particularly vulnerable to: A. Hypotension B. Fluid overload C. Cardiac arrhythmias D. Pulmonary emboli

1. A client with severe inflammatory bowel disease is receiving TPN. When

administering TPN, the nusre must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause: A. Hyperglycemia

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B. Air embolism C. Constipation D. Dumping syndrome Situation: Respiration is one of the most important vital sign. This is usually the first Vital sign to be assessed more than anything for it is easily altered by the patients consciousness. The nurse should be aware of the different changes and alteration in respiration. 1. Another name for an abnormal breath sound is: A. Adventurous breath sound B. Excursion C. Adventitious breath sound D. Dyspnea

1. In a client with diabetic ketoacidosis, Kussmauls respiration is exhibited. This

is evidence that there is the presence of: A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

1. If the nurse will auscultate the base of the lungs, it is expected that she will hear: A. Bronchovesicular B. Tubular C. Vesicular D. Crackles 1. The respiratory center is found in the: A. Pons B. Hypothalamus C. Medulla D. Lungs

1. Initially in asthma, you are expecting that the clients acid base disturbance is: A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis Situation: The physician has ordered 3 units of whole blood to be transfused to WQ following a repair of a dissecting aneurysm of the aorta. 1. You are preparing the first unit of whole blood for transfusion. From the time you obtain it from the blood bank, how long should you infuse it? A. 6 hours C. 4 hours B. 1 hour D. 2 hours 1. What should you do FIRST before you administer blood transfusion? A. verify client identity and blood product, serial number, blood type, cross matching results, expiration date B. verify client identity and blood product serial number, blood type, cross matching results, expiration date with another nurse C. check IV site and use appropriate BT set and needle D. verify physicians order 1. As WQs nurse, what will you do AFTER the transfusion has started? A. add the total amount of blood to be transfused to the intake and output B. discontinue the primary IV of Dextrose 5% Water C. check the vital signs every 15 minutes D. stay with WQ for 15 minutes to note for any possible BT reactions 1. WQ is undergoing blood transfusions of the first unit. The EARLIEST signs of transfusion reactions are:

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A. oliguria and jaundice B. urticaria and wheezing

C. hypertension and flushing D. headache, chills, fever

1. In case WQ will experience an acute hemolytic reaction, what will be your PRIORITY intervention? A. immediately stop the blood transfusion, infuse Dextrose 5% in Water and call the physician B. stop the blood transfusion and monitor the patient closely C. immediately stop the BT, infuse NSS, call the physician, notify the blood bank D. immediately stop the BT, notify the blood bank and administer antihistamines Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C. 1. Given the above assessment data, the most immediate goal of the nurse would be which of the following? A. Prevent urinary complication B. Maintains fluid and electrolytes C. Alleviate pain D. Alleviating nausea

1. After IVP a renal stone was confirmed, a left nephrectomy was done. Her post
operative order includes daily urine specimen to be sent to the laboratory . Eileen has a foley catheter attached to a urinary drainage system. How will you collect the urine specimen? A. remove urine from drainage tube with sterile needle and syringe and empty urine from the syringe into the specimen container B. empty a sample urine from the collecting bag into the specimen container C. disconnect the drainage tube from the indwelling catheter and allow urine to flow from catheter into the specimen container. D. disconnect the drainage the from the collecting bag and allow the urine to flow from the catheter into the specimen container. 1. Where would the nurse tape Eileens indwelling catheter in order to reduce urethral irritation? A. to the patients inner thigh C. to the patient buttocks B. to the patients lower thigh D. to the patient lower abdomen 1. Which of the following menu is appropriate for one with low sodium diet? A. instant noodles, fresh fruits and ice tea B. ham and cheese sandwich, fresh fruits and vegetables C. white chicken sandwich, vegetable salad and tea D. canned soup, potato salad, and diet soda 1. How will you prevent ascending infection to Eileen who has an indwelling catheter? A. see to it that the drainage tubing touches the level of the urine B. change he catheter every eight hours C. see to it that the drainage tubing does not touch the level of the urine D. clean catheter may be used since urethral meatus is not a sterile area Situation: The human body is a complex system of interrelated cells, tissues and organs that performs vital functions necessary to sustain life. Knowledge of basic anatomy is essential to understand how well our body adapts to the demands of life.

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1. What gland secretes the human growth hormone or the somatotropin? A. Hypothalamus C. Anterior pituitary gland B. Posterior Pituitary Gland D. Liver
1. The gland responsible for synthesizing and producing vasopressin or antidiuretic hormone is the: A. Hypothalamus C. Anterior pituitary gland B. Posterior Pituitary Gland D. Pancreas 1. RAAS effect A. B. or the rennin-angiotensin-aldosterone mechanism produces which in the body? Vasodilation and increase sodium and water reabsorption Vasoconstriction and decrease sodium and water reabsorption C. Vasodilation and decrease sodium and water resabsorption D. Vasoconstriction and increase sodium and water reabsoprtion

1. Hematopoiesis in a full grown adult occurs mainly in the: A. Red bone marrow C. Yellow bone marrow B. Liver D. Spleen 1. The respiratory center, which controls respiration, is located in the: A. Medulla Oblongata C. Hypothalamus B. Pons Varolii D. Lungs and Diaphragm Situation: Collaboration with the members of the healthcare team is an essential part of nursing practice. 1. If a client is concerned that he cannot pay the bill in due time, he will need a prompt referral to which department? A. Physician C. Social Service B. Library D. DSWD 1. Agatha has breast cancer and is going through chemotherapy. She was referred by the Oncology nurse to a self-help group of clients with cancer to: A. Have an emotional support C. For financial benefits B. Be part of a research experiment D. For legal benefits 1. The nurse should be aware the dietary department is also an important department in the collaborative team. Patient needing special instructions in their diets are referred to which of the following member of the collaborative team? A. The physician C. The nutritionist B. The dietician D. The pathologist 1. When Nurse A. B. collaborating with other health team members, the best description of Julies role is: Encourages the clients involvement in his care Shares and implements orders of the health team to ensure quality care C. She listens to the individual views of the team members D. Helps client set goals of care and discharge

1. Nurse Julie is successful in collaborating with health team members about the care of Mr. Santos. This is because she has the following competencies: A. Communication, trust, and decision making B. Conflict management, trust, negotiation C. Negotiation, decision making D. Mutual respect, negotiation and trust

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SITUATION: At the OPD, Miss Jean R.N assisted in the Physical examination of one patient for Paracentesis, Lumbar tap and Thoracentesis.

1. What instruction should the nurse include prior to paracentesis?

A. Ask the client to drink B. Ask the client to void C. Ask the client to be positioned on the unaffected side D. Ask the client to be positioned on the affected side 1. What is the position of the client prior to lumbar puncture? A. Quasifetal, flexed position B. Jacknife position C. Prone position D. Sidelying, on the unaffected side 1. Prior to Thoracentesis, the patient is placed on what position? A. Orthopneic position B. Dorsal recumbent position C. Lithotomy position D. Prone position 1. Prior to paracentesis, The client is asked to void first to: A. Test urine C. Prevent puncture bladder B. Prevent discomfort D. Prevent puncture uterus

of of

the the

1. In lumbar puncture, The flexed position of the patient is to: A. Achieve comfort C. Relax muscles B. Provide wide exposure of the back D. Widen the vertebral space Situation: You are a nurse conducting statistical analysis in your research entitled "The effect of Gingko Biloba in enhancing memory and retention of 4th year Highschool students." 1. What is the INDEPENDENT VARIABLE? A. The effect of Gingko Biloba B. Memory and Retention Retention 1. What is the DEPENDENT VARIABLE? A. The effect of Gingko Biloba B. Memory and Retention Retention C. Gingko Biloba Enhancing Memory

D.

and

D.

C. Gingko Biloba Enhancing Memory

and

1. The research design best used in this research is: A. Experimental C. Descriptive B. Non Experimental D. Qualitative 1. The hypothesis developed was: GINGKO BILOBA IMPROVES MEMORY AND RETENTION. This is an example of: A. Simple, Directional C. Complex, Directional B. Simple, Non Directional D. Complex, Non Directional

1. Gingko Biloba has an effect on memory and retention best describes which
type of hypothesis? A. Simple, Directional B. Simple, Non Directional C. Complex, Directional D. Complex, Non Directional

Situation: Survey and Statistics are important part of research that is necessary to explain the characteristics of the population.

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1. All but one of the following is not a measure of Central Tendency: A. Mode C. Standard Deviation B. Variance D. Range 1. It reflects the most frequent value that appears in the set data: A. Mean C. Median B. Mode D. Ratio 1. In the value: 87, 85, 88, 92, 90; What is the mean? A. 88.2 B. 88.4 C. 87 D. 90

1. In the value: 80, 80, 80, 82, 82, 90, 90, 100; What is the mode? A. 80
B. 82 C. 90 D. 85.5

1. In the value: 80, 80, 10, 10, 25, 65, 100, 200; What is the median? A. 71.25
B. 22.5 C. 10 and 25 D. 72.5

Situation: The Code of ethics is a bounding code the states the ethical behavior expected from nurses. 1. Values are said to be the enduring believe and belief. If Values are going to be a part under: A. Qualitative B. Quantitative about a worth of a person, ideas of a research, this is categorized C. Experimental D. Non Experimental

1. According to the code of ethics, which of the following is the primary responsibility of the nurse? A. Assist towards peaceful death B. Health is a fundamental right C. Promotion of health, prevention of illness, alleviation of suffering and restoration of health D. Preservation of health at all cost 1. Which of the following is TRUE about the Code of Ethics of Filipino Nurses? A. The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics for Nurses which the Board of Nursing promulgated B. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates C. The present code utilized the Code of Good Governance for the Professions in the Philippines D. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. 1. Violation of the code of ethics might equate to the revocation of the nursing license. Who revokes the license? A. PRC B. PNA C. DOH D. BON 1. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability? A. Human rights of clients, regardless of creed and gender B. The privilege of being a registered professional nurses C. Health, being a fundamental right of every individual D. Accurate documentation of actions and outcomes

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